Missouri's Unprecedented Push to Ease the Doctor Shortage

Missouri is likely the first state to pass a law that lets medical school graduates practice primary care in underserved areas without completing a residency.

A nurse practitioner works on patient paperwork at a rural clinic in Pilot Grove, Mo. In 2007, the town had no doctor. AP/Dan Gill

A new Missouri law allows recent medical school graduates to practice primary care in underserved areas without completing a residency in a teaching hospital.

The Missouri State Medical Association, the law’s chief backer, is calling it an unprecedented effort to help deal with doctor shortages in rural and other underserved areas, but opponents raise questions about whether circumventing the traditional path to the exam room will do more harm than good.

A 2009 study found that 40 percent of Missouri's residents live in rural areas while only 25 percent of the state’s doctors practice there. Nationally, about 25 percent of the U.S. population lives in rural areas while only 10 percent of physicians practice there, according to the National Rural Health Association. "Underserved" areas are those with a low ratio of primary care doctors per 1,000 residents, high infant mortality rates, and/or large populations of senior citizens and people living below the poverty level.

As the baby boomer generation ages and more people get health insurance, the nation faces a shortage of more than 90,000 doctors by 2020 and more than 130,000 by 2025, according to the Association of American Medical Colleges. Such statistics have prompted state legislatures over the past several years to pass scope-of-practice bills that, among other things, expand nurse practitioners' authority so that they can independently take on more of doctors' duties like diagnosing illnesses and prescribing medicine for some ailments.

Medical students have long participated in residency assignments at teaching hospitals after graduation to round out their education in a practical setting under the guidance of professionals. Every state requires them to complete at least a yearlong residency before applying for a medical license -- unless they want to practice in rural Missouri.

Missouri’s law, signed by Gov. Jay Nixon earlier this month, carves out a new classification called “assistant physician.” The law allows medical school graduates who have completed their licensing exams but haven't finished a residency to practice immediately in underserved areas. These graduates have to join a primary care practice of a “collaborating physician” who agrees to accept responsibility for an assistant physician. An assistant physician, who can legally be called a doctor, has to practice continually with his or her collaborating physician for one month before being able to serve independently.

Jeff Howell, a lobbyist for the Missouri State Medical Association, argues the law provides a way to address doctor shortages in a cost-effective way as the number of residencies remains largely static and other incentives to encourage graduates to practice in underserved areas remain underfunded. With the number of federally funded residency training positions capped by a 1997 law and a dysfunctional Congress, it’s difficult to see the possibility of movement on that issue in the near future.

“I think it’s a workable alternative,” Howell said. “People can say we need to push for more funding for residency spots, but they’ve been pushing for that for years and nothing has happened. You can’t just continue to wish.”

The total number of residency applicants has exceeded the total number of positions available since the 1980s. In 2014, 29,671 available positions were filled by 28,490 students, but the number of active applicants topped 34,000. About 7,000 of those were non-U.S. citizens who graduated from international schools, and about half of them found residencies.

Given those numbers, Howell sees the potential to boost the state's primary care workforce with graduates who choose to stay in Missouri as well as international students and graduates from other states who may flock to Missouri.

There's no legal limit to how many years assistant physicians can practice, but Howell envisions graduates will use the position as a learning experience before entering a formal residency. The state medical board wouldn't say whether it's considering limiting the number of times an assistant physician can renew a license or whether it has the authority to do so.

But the idea that these recent graduates will be practicing totally independently is overblown, Howell argues. “They’ll still be in collaboration with a licensed physician. That collaborative practice never disappears.”

But still, some medical experts like Rosemary Gibson, a board member at the Accreditation Council for Graduate Medical Education, are warning other states not to follow Missouri's lead because rural residents are sicker, older and poorer, on average, than the country as a whole. She said the Missouri law goes well beyond the scope-of-practice laws that have popped up in state legislatures.

“On the surface, it looks like a quick fix, but I think it really behooves [policymakers] to do their homework, to understand what it means to have a graduate of a medical school be called doctor, to have prescriptive authority for powerful drugs like narcotics, to accurately dose and treat people,” she said. “Primary care is not simple. If you have a lot of older people living in rural areas, they have a lot of co-morbidities [such as diabetes combined with heart disease].”

Missouri’s state medical board isn’t taking a position on the law but is required to set the licensing rules for assistant physicians. The Missouri Hospital Association didn’t take a position but is offering to assist in the rule-writing.

Last month, the American Medical Association formally opposed special licensing pathways for physicians who aren’t enrolled in an accredited post-graduate program or have at least one year of additional education in the United States under their belt. The reason is simple, said Atul Grover, the chief public policy officer at the Association of American Medical Colleges: Their education is often grounded in theoretical and academic work with the assumption that a future doctor will spend time in a residency afterward.

“That education is designed to pair them up with residency,” he said. “It’s not designed to pair them up with immediate independent practice.”